HESI Case Studies - Psychiatric/Mental
Health - Psychosis (Adam Monroe) Actual
Exam Questions and CORRECT Answers
1. Which thought process describes the client's inability to leave his apartment because he
thought someone was waiting to kill him? - CORRECT ANSWER✔✔- Delusions
A delusion is a false belief that is firmly maintained even though it is not shared by others and
is contraindicated by reality
2. When the client explains that someone has been following him and is waiting outside the
door of the ED, how should the nurse respond? - CORRECT ANSWER✔✔- "You must be
concerned, but you are safe here."
The nurse should respond to the client's underlying feelings and not make assumptions about
his delusions.
3. Which term fits the nurse's observation that the client looks to the corner of the room and
mumbles to himself? - CORRECT ANSWER✔✔- Hallucinations
Hallucinations can be nonverbal or they can include talking to oneself, moving the lips
without making sounds, rapid eye movements, and grinning or inappropriate laughter
4. When the client looks around the room and mumbles to himself, how should the nurse
respond? - CORRECT ANSWER✔✔- "Are you hearing voices?"
The client is demonstrating nonverbal cues that he is experiencing auditory hallucinations, so
the nurse should ask the client if he is hearing voices
5. The client admits that the voices he hears have been getting louder over the past couple of
weeks. Which question should the nurse ask next? - CORRECT ANSWER✔✔- "What do
the voices say?"
, There nurse should first ask what the voices are saying in order to assess for command
hallucinations
6. Which medication(s) should the nurse anticipate giving the client after securing a
prescription from the healthcare provider? (Select all) - CORRECT ANSWER✔✔- -Short-
acting anxiolytic (benzodiazepines)
Antianxiety mediations (benzodiazepines, lorazepam clonazepam, or diazepam) are most
effective for anxiety-related symptoms to produce calming & sedation. When used in
conjunction with an atypical antipsychotic medication, such as olanzapine, benzodiazepines,
especially IM, can augment the efficacy of the antipsychotic medication, quickly alleviating
acute agitation of a client
-Antipsychotic medication
Antipsychotic medications are effective for psychosis-related symptoms and manifestations
of agitation associated with mental illness
7. Which assessment data provides evidence that Adam can be involuntarily committed to the
hospital, if he insists on leaving? - CORRECT ANSWER✔✔- Losing 10 pounds in 2 weeks
The criteria for commitment includes danger to self and/or others, unable to provide for own
basic needs, and/or the need for immediate and adequate treatment. Excessive weight loss
demonstrates Adam's inability to provide for his own basic needs by not maintaining
adequate nutrition
8. What is the most important part of this admission process? - CORRECT ANSWER✔✔-
Take away Adam's cigarettes and lighter
Safety for the client and the unit environment is the highest priority, so the staff should keep
any potentially dangerous objects away from the client
9. Which assessment data are the best indicators of the potential for violence? (Select all) -
CORRECT ANSWER✔✔- -Past suicide attempts
Past suicide attempts are indicators of violence toward self
-History of violence
Health - Psychosis (Adam Monroe) Actual
Exam Questions and CORRECT Answers
1. Which thought process describes the client's inability to leave his apartment because he
thought someone was waiting to kill him? - CORRECT ANSWER✔✔- Delusions
A delusion is a false belief that is firmly maintained even though it is not shared by others and
is contraindicated by reality
2. When the client explains that someone has been following him and is waiting outside the
door of the ED, how should the nurse respond? - CORRECT ANSWER✔✔- "You must be
concerned, but you are safe here."
The nurse should respond to the client's underlying feelings and not make assumptions about
his delusions.
3. Which term fits the nurse's observation that the client looks to the corner of the room and
mumbles to himself? - CORRECT ANSWER✔✔- Hallucinations
Hallucinations can be nonverbal or they can include talking to oneself, moving the lips
without making sounds, rapid eye movements, and grinning or inappropriate laughter
4. When the client looks around the room and mumbles to himself, how should the nurse
respond? - CORRECT ANSWER✔✔- "Are you hearing voices?"
The client is demonstrating nonverbal cues that he is experiencing auditory hallucinations, so
the nurse should ask the client if he is hearing voices
5. The client admits that the voices he hears have been getting louder over the past couple of
weeks. Which question should the nurse ask next? - CORRECT ANSWER✔✔- "What do
the voices say?"
, There nurse should first ask what the voices are saying in order to assess for command
hallucinations
6. Which medication(s) should the nurse anticipate giving the client after securing a
prescription from the healthcare provider? (Select all) - CORRECT ANSWER✔✔- -Short-
acting anxiolytic (benzodiazepines)
Antianxiety mediations (benzodiazepines, lorazepam clonazepam, or diazepam) are most
effective for anxiety-related symptoms to produce calming & sedation. When used in
conjunction with an atypical antipsychotic medication, such as olanzapine, benzodiazepines,
especially IM, can augment the efficacy of the antipsychotic medication, quickly alleviating
acute agitation of a client
-Antipsychotic medication
Antipsychotic medications are effective for psychosis-related symptoms and manifestations
of agitation associated with mental illness
7. Which assessment data provides evidence that Adam can be involuntarily committed to the
hospital, if he insists on leaving? - CORRECT ANSWER✔✔- Losing 10 pounds in 2 weeks
The criteria for commitment includes danger to self and/or others, unable to provide for own
basic needs, and/or the need for immediate and adequate treatment. Excessive weight loss
demonstrates Adam's inability to provide for his own basic needs by not maintaining
adequate nutrition
8. What is the most important part of this admission process? - CORRECT ANSWER✔✔-
Take away Adam's cigarettes and lighter
Safety for the client and the unit environment is the highest priority, so the staff should keep
any potentially dangerous objects away from the client
9. Which assessment data are the best indicators of the potential for violence? (Select all) -
CORRECT ANSWER✔✔- -Past suicide attempts
Past suicide attempts are indicators of violence toward self
-History of violence
